Diagnosis and Treatment of Chronic Neuropathic and Mixed Pain in Children and Adolescents: Results of a Survey Study amongst Practitioners

Validated diagnostic tools to diagnose chronic neuropathic and mixed pain in children are missing. Therapeutic options are often derived from therapeutics for adults. To investigate the international practice amongst practitioners for the diagnosis and treatment of chronic, neuropathic pain in children and adolescents, we performed a survey study among members of learned societies or groups whose members are known to treat pediatric pain. The survey included questions concerning practitioners and practice characteristics, assessment and diagnosis, treatment and medication. We analyzed 117 returned questionnaires, of which 41 (35%) were fully completed and 76 (65%) were partially completed. Most respondents based the diagnosis of neuropathic pain on physical examination (68 (58.1%)), patient history (67 (57.3%)), and underlying disease (59 (50.4%)) combined. Gabapentin, amitriptyline, and pregabalin were the first-choice treatments for moderate neuropathic pain. Tramadol, ibuprofen, amitriptyline, and paracetamol were the first-choice treatments for moderate mixed pain. Consensus on the diagnostic process of neuropathic pain in children and adolescents is lacking. Drug treatment varies widely for moderate, severe neuropathic, and mixed pain. Hence, diagnostic tools and therapy need to be harmonized and validated for use in children

Symptomatic Management of Fever in Children: A National Survey of Healthcare Professionals' Practices in France.

Despite the production and dissemination of recommendations related to managing fever in children, this symptom saturates the practices of primary healthcare professionals (HPs). Data on parent practices related to fever are available, but data on HPs' practices are limited. We studied HPs' practices, determinants of practices and concordance with recommendations in France. We conducted a national cross-sectional observational study between 2007 and 2008 among French general practitioners, primary care pediatricians and pharmacists. HPs were asked to include 5 consecutive patients aged 1 month to 12 years with acute fever. HPs completed a questionnaire about their practices for the current fever episode. We used a multilevel logistic regression model to assess the joint effects of patient- and HP-level variables associated with this behavior. In all, 1,534 HPs (participation rate 13%) included 6,596 children (mean age 3.7 ± 2.7 years). Physicians measured the temperature of 40% of children. Primary HPs recommended drug treatment for 84% of children (including monotherapy for 92%) and physical treatment for 62% (including all recommended physical treatments for 7%). HPs gave written advice or a pamphlet for 13% of children. Significant practice variations were associated with characteristics of the child (age, fever level and diagnosis) and HP (profession and experience). In France, despite the production and dissemination of national recommendations for managing fever in children, primary HPs' observed practices differed greatly from current recommendations, which suggests potential targets for continuing medical education

Recommendations for 5 key steps in managing fever in children and parental concordance with recommendations by healthcare professional consulted.

<p>^a Concordance with recommendations of our study.</p><p>^b For patients with fever for ≥24 hr (n = 2,559).</p

Summary of actors associated with high concordance with recommendations for the 5 key steps in managing fever symptoms in children (see details including confidence intervals in appendix 2 to 6).

<p>^a Adjusted odds ratio (aOR) for patient- or HP-level variables with P<0.1 on univariate analysis.</p><p>^b At the patient-level, no association was found between any of the 5 steps and the child's gender and birth order.</p><p>P≤0.05;</p><p>^c At the HP-level, no association was found between any of the 5 steps and practice location.</p><p>^d HP, healthcare professional;</p><p>^e GP, general practitioner.</p

Healthcare professionals’ practices for fever in children and concordance with recommendations.

<p>*no. of children recruited.</p><p>AAP, American Academy of Pediatrics; NICE, UK National Institute for Health and Clinical Excellence; Afssaps, French Drug Agency; CPS, Canadian Paediatric Society</p><p>^μ Percentage calculated on available data (n’)</p><p>^a Recommended physical treatments in our study.</p><p>^b Increase heating, not aerate the room, use a ventilator, dress the child, use a wet sponge, humidify the room.</p><p>^c Concordance with recommendations of our study.</p><p>Healthcare professionals’ practices for fever in children and concordance with recommendations.</p

Fibromyalgie

La fibromyalgie, ou syndrome fibromyalgique, est une forme de douleur chronique diffuse associée à d’autres symptômes tels que fatigue, troubles du sommeil et de l’humeur, troubles cognitifs, déconditionnement physique... En France, sa prévalence est estimée à environ 1,6 %.L’étiologie et la physiopathologie de la fibromyalgie sont complexes, impliquant de nombreux facteurs biologiques, psychologiques et sociaux. Ses critères de classification et de diagnostic en constante évolution et l’absence de signes cliniques et biologiques spécifiques rendent encore son diagnostic difficile à poser. De plus, la nécessité de sa prise en charge est parfois sous-estimée alors que la fibromyalgie altère la qualité de vie dans de très nombreuses dimensions (restriction d’activités, handicap moteur invalidant, arrêts de travail prolongés, etc.).Cette expertise collective Inserm, sollicitée par la Direction générale de la santé, dresse un bilan des connaissances issues des recherches internationales menées sur la fibromyalgie. Le groupe d’experts pluridisciplinaire a structuré son analyse autour des aspects bio-psycho-sociaux, des prises en charge multimodales et des hypothèses étiologiques de la fibromyalgie chez l’adulte mais aussi chez l’enfant et l’adolescent. Le groupe d’experts propose des recommandations d’actions et de recherches dans la perspective d’améliorer l’efficacité de la prise en charge individuelle des patients afin de trouver une réponse la plus adaptée à leur symptomatologie

The research gap in chronic paediatric pain : A systematic review of randomised controlled trials

Background and Objective: Chronic pain is associated with significant functional and social impairment. The objective of this review was to assess the characteristics and quality of randomized controlled trials (RCTs) evaluating pain management interventions in children and adolescents with chronic pain. Methods: We performed a systematic search of PubMed, Embase and the Cochrane Library up to July 2017. We included RCTs that involved children and adolescents (3 months-18 years) and evaluated the use of pharmacological or non-pharmacological intervention(s) in the context of pain persisting or re-occurring for more than 3 months. Methodological quality was evaluated using the Cochrane Risk of Bias (ROB) Tool. Results: A total of 58 RCTs were identified and numbers steadily increased over time. The majority were conducted in single hospital institutions, with no information on study funding. Median sample size was 47.5 participants (Q1,Q3: 32, 70). Forty-five percent of RCTs included both adults and children and the median of the mean ages at inclusion was 12.9 years (Q1,Q3: 11, 15). Testing of non-pharmacological interventions was predominant and only 5 RCTs evaluated analgesics or co-analgesics. Abdominal pain, headache/migraine and musculoskeletal pain were the most common types of chronic pain among participants. Methodological quality was poor with 90% of RCTs presenting a high or unclear ROB. Conclusions: Evaluation of analgesics targeting chronic pain relief in children and adolescents through RCTs is marginal. Infants and children with long-lasting painful conditions are insufficiently represented in RCTs. We discuss possible research constraints and challenges as well as methodologies to circumvent them. Significance: There is a substantial research gap regarding analgesic interventions for children and adolescents with chronic pain. Most clinical trials in the field focus on the evaluation of non-pharmacological interventions and are of low methodological quality. There is also a specific lack of trials involving infants and children and adolescents with long-lasting diseases

The research gap in chronic paediatric pain: A systematic review of randomised controlled trials

Background and Objective: Chronic pain is associated with significant functional and social impairment. The objective of this review was to assess the characteristics and quality of randomized controlled trials (RCTs) evaluating pain management interventions in children and adolescents with chronic pain. Methods: We performed a systematic search of PubMed, Embase and the Cochrane Library up to July 2017. We included RCTs that involved children and adolescents (3Â&nbsp;months-18Â&nbsp;years) and evaluated the use of pharmacological or non-pharmacological intervention(s) in the context of pain persisting or re-occurring for more than 3Â&nbsp;months. Methodological quality was evaluated using the Cochrane Risk of Bias (ROB) Tool. Results: A total of 58 RCTs were identified and numbers steadily increased over time. The majority were conducted in single hospital institutions, with no information on study funding. Median sample size was 47.5 participants (Q1,Q3: 32, 70). Forty-five percent of RCTs included both adults and children and the median of the mean ages at inclusion was 12.9Â&nbsp;years (Q1,Q3: 11, 15). Testing of non-pharmacological interventions was predominant and only 5 RCTs evaluated analgesics or co-analgesics. Abdominal pain, headache/migraine and musculoskeletal pain were the most common types of chronic pain among participants. Methodological quality was poor with 90% of RCTs presenting a high or unclear ROB. Conclusions: Evaluation of analgesics targeting chronic pain relief in children and adolescents through RCTs is marginal. Infants and children with long-lasting painful conditions are insufficiently represented in RCTs. We discuss possible research constraints and challenges as well as methodologies to circumvent them. Significance: There is a substantial research gap regarding analgesic interventions for children and adolescents with chronic pain. Most clinical trials in the field focus on the evaluation of non-pharmacological interventions and are of low methodological quality. There is also a specific lack of trials involving infants and children and adolescents with long-lasting diseases